Download The Drug Regimen Review

CHAPTER 13
MONITORING DRUG THERAPY IN THE NURSING HOME
(THE MEDICATION REGIMEN REVIEW)
13.1
NURSING HOME
MONITORING DRUG THERAPY IN THE NURSING HOME
I. Types Of Medication Regimen Reviews
1. Prospective MRR – the review of drug therapy is done at the time of admission
2. Concurent MRR – the review of drug therapy is completed while the therapy is in
progress
3. Retrospective MRR – the review of drug therapy is completed after the therapy has
been completed or the patient has been discharged
*II. The key areas of the chart reviewed by the Consultant Pharmacist and the
information obtained from each area of the chart
1. The Physician Order Sheet (P.O.S.)
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Current medication orders including the drug name, strength, frequency and possibly the length of therapy
Cumulative diagnoses on the patient. In some cases the P.O.S. will also identify supporting diagnoses for
each routine drug in use.
The prescriber for each medication
Ancillary orders
Diet
Physician signature indicating the date of his/her review
The P.O.S. may also include new orders written in-house since the beginning of the month
2. The Telephone Orders written since the last review
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New medication orders written since the beginning of the month
Discontinued orders since the beginning of the month
Whether the prescriber has reviewed and countersigned the telephone order
The T.O. may also include a supporting diagnosis for the new order
3. The Medication Administration Record (M.A.R.) & PRN sheets
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The administration times for each medication in use
All medications that have been discontinued since the first of the month
All new medications started since the first of the month
Doses of medication held and the reason they were held
Charting omissions that may compromise the effectiveness of the therapy
The use of PRN doses for the patient and the effectiveness of each dose
Doses that are being crushed or administered through a tube
4. The Psychoactive Drug Flow Sheet
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The target behavior being measured to document therapy effectiveness
The frequency of behaviors by day and shift
Non-drug interventions that may be effective in controlling behaviors
Side Effects identified that are possibly related to the psychoactive therapy
The impact of dosage adjustments on the frequency of target behaviors
13.2
5. The Nursing Notes
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Vital signs
Bowel and bladder function
Pain levels
Falls and other incidents
Resident comments that may indicate mental state
Sleep patterns
Symptoms of developing conditions such as edema, cough, temperature
Side effects of current therapy such as drowsiness, GI pain, constipation
Effectiveness of new therapy
6. The Physician Progress notes
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The physician’s assessment of the patient’s condition
The physician’s rationale for choosing a new medication
The physician’s plan for treating the patient
7. Lab reports taken since the last review
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Date and “draw time” for all laboratory tests completed
Type of labs completed
Previous labs for comparison with current results
Sub-therapeutic and toxic levels
8. The M.D.S.
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Former habits and work history
Pain status
History of falls
History of depression and other behavioral symptoms
History of chronic disease that may not appear on the P.O.S.
History of medications and allergies
9. The resident’s Care Plan
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The proposed treatment plan
The effectiveness of previous therapy
The impression of facility staff regarding patient’s rehab potential
Mental status and the results of non-drug interventions
Future plans for care and therapy
III. Federal Indicators used in the Medication Regimen Review
*1. F329 - Unnecessary Medications
*2. F428 - Drug Regimen Review
*3. F425 - Pharmacy Services
4. F272 - Resident Assessment
5. F315 - Urinary Incontinence
6. F319 - Mental and Psychosocial Functioning
(* - of primary importance)
13.3
NURSING HOME
*IV. What are we looking for during the Medication Regimen Review?
1.
2.
3.
4.
5.
6.
7.
8.
9.
Review new orders to rule out the possibility of treating an unidentified adverse effect
Review nursing notes to rule out unidentified adverse drug reactions
Make sure that all doses are within normal geriatric range
Make sure duration of therapy is appropriate
Make sure that dosage reductions are attempted on the anxiolytic and antipsychotic drugs
Make sure there is a supporting diagnosis for each order
Make sure there are no untreated conditions
Review PRN drug usage to ensure they are not becoming routine orders
Review Lab values to identify sub-therapeutic or toxic levels or Irregularities caused by
current therapy
10.Pharmacy service issues such as untimely deliveries and out of stock
medications that may adversely affect the patients outcome.
V. Other issues that may be picked up during the MRR
1. Physician orders not being signed monthly
2. Telephone Orders not signed in a timely manner
3. New orders written in the chart but never ordered from pharmacy or
initiated on the Medication Administration Record (MAR)
*VI. Documentation required by the consultant to prove the MRR was completed
1
Review the drug therapy of each resident at least monthly.
Unstable patients or high acuity facilities may require more frequent chart reviews by the
consultant pharmacist. As an example, a sub-acute facility may require weekly or every
other week medication regime reviews
2. Sign and date each Resident’s chart monthly
3. Document any areas of concern in a written note
4. Document “No Irregularities Noted” if there are no concerns
5. Prepare a monthly report that summarizes the entire M.R.R. for the
Director of Nursing and Medical Director
6
Follow up on previous recommendations to ensure that every Prescriber
has responded
7. Prepare a quarterly report that summarizes the past 3 months of consultant
activities in the facility
13.4
NURSING HOME
SAMPLE POLICY & METHODS
Medication Regimen Review
Policy:
The consultant pharmacist or his agent will review the drug regimen of each Resident at
least monthly and report, in writing, any irregularities. For the purposes of this policy, the
term irregularity shall mean failing to be in accord with what is usual, proper, accepted, or
right.
Methods:
1.
The consultant pharmacist will provide the facility with documentation that each
resident’s drug regimen has been reviewed by signing and dating the monthly
physician’s drug summary.
2.
The consultant pharmacist will provide to the director of nursing each month a
written report with a statement about each resident and any irregularities found. If
no irregularities were noted this shall be so noted. This report will be signed and
dated by the consultant pharmacist and all irregularities will be highlighted to
indicate that some action is required by nursing. The director of nursing will
respond in writing on the report what action had been taken on those irregularities
so reported. This completed report will be made available to and signed by the
administrator and medical director and retained in the facility for one year. A
summary of these reports will be made quarterly by the consultant pharmacist to
the Quality Assessment and Assurance Committee.
3.
The consultant pharmacist will provide a copy of the above report to the medical
director each month. The medical director will review, make comments, and sign
the report. It shall be returned to the director of nursing and retained in the facility
for one year.
4.
The consultant will be available by pager or cell phone and should be contacted by
nursing whenever a new patient is admitted or a drug related event is suspected by
the nursing staff. The consultant will make arrangements to review the apparent
event (or new admission) and provide the facility with a written report within 24
hours of the review.
5.
The facility will forward the interim consultant review to the attending
physician via fax followed by a phone call (when necessary) so that any
identified problems can be addressed by the prescriber in a timely manner.
13.5
Extracted from: Nursing Homes - Clarification of
Guidance related to Medication Errors and
Pharmacy Services - CMS November 2012
III. Medication Regimen Reviews for Stays under 30 days and Changes in Condition
Consultation (including medication regimen review) by the pharmacist can
promote safe and effective medication use. The regulation at F428-Medication
Regimen Review requires that a licensed pharmacist review each resident’s
medication regimen at least once a month.
The facility is expected to have a proactive, systematic and effective approach to
monitoring, reporting, and acting upon the effects, risks, and adverse consequences of
medications. The pharmacist may need to conduct the medication regimen review
more frequently (for example weekly), depending on the resident’s condition and the
risks for adverse consequences related to current medications. The requirement for the
medication regimen review applies to all residents, including residents receiving respite
care, residents at the end of life or who have elected the hospice benefit, residents with
an anticipated stay of less than 30 days, or residents who have experienced a change
in condition. Complex residents generally benefit from a pharmacist’s review during
the transition from hospital to skilled nursing facility.8 This review may prevent
Errors due to drug-drug interactions, omissions, duplication of therapy or
miscommunication during the transition from one team of care providers to another.
13.6
The current guidance at F425-Pharmacy Services provides examples of how the facility, in
collaboration with the pharmacist and medical director, can establish procedures to address
medication regimen reviews for residents whose anticipated stay is less than 30 days.
According to the guidance, facility procedures are expected to address how and when
the need for a consultation will be communicated, how the medication review will be
handled if the pharmacist is off-site, how the results or report of the pharmacist’s
findings will be communicated to the provider, the expectations for the provider’s
response and follow up, and how and where this information will be documented.
Survey Implications:
Both the previous and the current guidance at F428-Medication Regimen Review
have identified that the pharmacist may need to review a medication regimen more
frequently, depending on the resident’s condition and the risk for adverse
consequences associated with the medications. Efforts to prevent medication-related
adverse consequences and to recognize existing or emerging complications are a
significant focus of clinical care in nursing homes. If there is evidence the pharmacist
should have conducted more frequent reviews, surveyors should consider consulting
an advanced practitioner, pharmacist or physician at the State Survey Agency or
Regional Office to review cases in which this practice may be considered deficient.
If non-compliance has been identified at F428, then additional requirements
may also be considered and investigated such as F385-Physician
Supervision; F329-Unnecessary Medications; or F501-Medical Director.
For questions on this memorandum, please contact [email protected].
Effective Date: Immediately. This policy should be communicated with all survey and
certification staff, their managers and the State/Regional Office training coordinators
within 30 days of this memorandum.
13.7
SAMPLE PROSPECTIVE MEDICATION REGIMEN
REVIEW CHECKLIST
Resident:___________________________________Date:_______________Facility:________________Wing:___
___________________________ Room #:______________ Physician:__________________________
Pharmacist Reviewer: _____________________________
R.Ph. Phone:_______________________
The following recommendations were made:
No Recommendations Made.
Drug Stop Date Request:______________________________________________________________
Drug information Request Provided to Nurse or Physician:___________________________________
Regarding the following:_____________________________ Reference(s):_____________________
More information needed before request can be processed. Explain: ___________________________
AIMS review with antipsychotic use initially and every 6 months.
Drug Therapy Intervention Requests. If accepted by MD, must have a separate physician order.
Drug
Directions
Recommendation
Reason
Reason: 1-Change to formulary drug, 2-Therapeutic interchange, 3-Less cost, 4-Improved patient care, 5-Incomplete
directions, 6-Not for use in elderly, 7-Duplicate therapy, 8-Inappropriate dosing, 9-Allergy,
10-Drug interaction, 11-Drug/disease interaction.
Medications Requiring Diagnosis(es).
Fax to Pharmacy when Complete.
Medication
Diagnosis
Nurse:_______________________________
Date:________________________________
Request for Laboratory Monitoring:
___Glucose
Frequency:________________
___Potassium
Frequency:________________
___Digoxin Level
Frequency:________________
___CBC
Frequency:________________
___Carbamazepine
Frequency:________________
___Valproic Acid
Frequency:________________
___PT/INR
Frequency:________________
___Phenytoin Level
Frequency:________________
___TSH
Frequency:________________
___BUN/Creatinine
Frequency:________________
Physician:_________________________________
Date:______________________________________
13.8
PROSPECTIVE MEDICATION REGIMEN
REVIEW CHECKLIST
Resident:___________________________________Date:_______________Facility:______________________Wi
ng:______________________________ Room #:______________ Physician:__________________________
Pharmacist Reviewer: _________________________________R.Ph.
Phone: ___________________________
The following recommendations were made:
No Recommendations Made.
Drug Stop Date Request:_____________________________________________________________________
Drug information Request Provided to Nurse or Physician:__________________________________________
Regarding the following:____________________________________ Reference(s):_____________________
More information needed before request can be processed. Explain:___________________________________
AIMS review with antipsychotic use initially and every 6 months. Drug: ______________________________
The following is a condensed list of medications that may require additional clinical monitoring. The proposed
monitoring are recommendations only, however they do reflect recommendations found in Tag F329. If
monitoring took place in the hospital and results are available to the facility it may be appropriate to delay
additional laboratory testing at this time.
DRUG
LAB TEST & FREQUENCY
ACE Inhibitors Drug: _______________________________
Angiotensin Receptor Blockers:_______________________
Chem-7 Q 6-12 months
Chem-7 Q 6-12 months
Allopurinol (Zyloprim)
Chem-7, Uric Acid Q 6-12 months
Aminoglycosides Antibiotics (Gentamycin, Tobramycin) &
Vancomycin
Peak and trough levels + Creatinine Clearance
Amiodarone (Cordarone)
LFT's, TSH, CBC Q 6-12 months
Anticoagulants
CBC Q6 months
Appetite Stimulants Drug:______________________
Appetite and weight should be monitored and agent should be dc'ed if there is
no improvement
Atypical Antipsychotics (Abilifty, Geodon, Risperdal, Seroquel &
Zyprexa)
Fasting Bloog Glucose monthly x 3 months then quarterly. Lipid profile
(including Total Cholesterol) baseline + annually.
Carbamazepine (Tegretol, Carbatrol)
LFT's, CBC, Serum level Q6 months + Serum level 7 days after each dosage
adjustment
Cholestyramine (Questran)
May interact with medications given at the same time. Separate by at least 1
hour before or 4 hours after Questran dose. Lipid Profile Q6-12 months
Clozapine (Clozaril)
CBC weekly or bi-weekly depending on past lab history
Digoxin (Lanoxin)
Serum Digoxin level Q6-12 months and whenever side effects are suspected.
Pulse daily
Diuretics Drug:________________________
Erythropoiesis Stimulating Agent (Epogen, Procrit & Aranesp)
Folic Acid
Chem-7 and or Electrolytes within 30 days of therapy initiation + Q6 months.
Blood Pressure weekly.
CBC twice weekly during dose adjustments and monthly therafter. Some
insurance plans require Ferritin & TIBC levels for prior approval.
CBC Q6 months. Folate level if needed
Glyburide (Diabeta) & Chlorpropamide (Diabinese)
Fasting Blood Glucose at least Q60 days + HgA1c quarterly. These products
should be avoided in the elderly due to their long half life and greater risk of
hypoglycemia
Heparin SQ
CBC baseline
Hydrochlorthiazide
Chem-7 and or Electrolytes within 30 days of therapy initiation + Q6 months.
SCr Q6 months. Blood Pressure weekly.
Insulin
Fasting Blood Glucose at least Q60 days + HgA1c quarterly
Drug: _________________________
FACILITY NAME: __________________________ RESIDENT’S NAME: ____________________________
13.9
DRUG
LAB TEST & FREQUENCY
Iron Supplements Drug: _______________________
CBC within 30 days of therapy initiation then Q6 months. TIBC, Serum Ferritin,
Serum Iron yearly (CBC, TIBC, Serum Ferritin, Serum Iron, Reticulocyte Count,
Transferrin Saturation to determine Iron deficiency anemia)
Lithium (includes Lithobid & Lithium Citrate)
Serum level Q week until stable, then monthly. Chem-7, TSH and CBC Q6
months
Metformin (Glucophage)
SCr, BUN Q6 months, Fasting Blood Glucose Q60 days + HgA1c quarterly.
This drug has been linked to lactic acidosis especially in males with serum
creatinine > 1.5mg/dL and in females with serum creatinine > 1.4mg/dL
Nitrofurantoin (Macrodantin or Macrobid)
SCr, BUN within 30 days of starting therapy then Q6 months Should not be
used if renal function is impaired (CrCl <60) due to decreased effectiveness &
increased side effects
Non-Steroidal Anti-Inflammatory Drugs (NSAID)
Drug_______________________
CBC, Chem-7 Q 6months. Monitor closely for bleeding especially when coadministered with Aspirin >325mg/day or when used with platlet inhibitors or
anticoagulants
Oral Hypoglycemics
Fasting Blood Glucose at least Q60 days + HgA1c quarterly
Phenobarbital
Serum level Q6 months + Serum level 7 days after each dosage adjustment
Phenytoin (Dilantin)
CBC, Serum Albumin and Serum level Q6 months + Serum level 7 days after
each dosage adjustment
Potassium Supplements
Drug:___________________
Chem-7 Q6 months
Rosiglitazone (Avandia) & Pioglitazone (Actos)
These agents can cause weight gain and edema. Monitor weight.
Statin Drugs Drug: __________________________
Baseline LFT's before starting therapy, then in 12 weeks after starting therapy
or increasing dose. LFT's and Lipid Profile Q6-12 months
Synthetic Heparin products (Lovenox, Fragmin, etc)
CBC baseline
Theophylline
Serum Theophylline level Q6 months
Thyroid Supplements
TSH, annually and 6 weeks after each dosage adjustment
Urinary anti-infectives
Chronic infections treated with prophylactic therapy - UA 30 days following the
start of therapy
Valproic Acid (includes Depakene & Depakote)
LFT's, CBC, Serum level Q6 months + Serum level 7 days after each dosage
adjustment
Vitamin B-12
CBC Q6 months. B-12 level if needed
Warfarin (Coumadin)
INR daily to weekly on initiation until stable - then INR weekly to monthly
[ ] Hospital Lab results are available in chart.
MISSING DIAGNOSES
DRUG
SUPPORTING DIAGNOSIS
DRUG INTERACTION NOTIFICATION
The following medication(s) may have the potential to result in a drug interaction. Please assess the risk versus
benefit for the concomitant use of the following medications:
[ ] I authorized the above recommendations
[ ] I do not wish to implement the above recommendations
Physician:_________________________________
13.10
Reason: _______________________________
Date:______________________________________
CONSULTANT PHARMACIST M.R.R. SIGNATURE LOG
YEAR:
MONTH
PATIENT NAME:
SIGNATURE
REVIEW DATE
____________________
NOTES
JANUARY
[ ] No Irregularities Noted
FEBRUARY
[ ] No Irregularities Noted
MARCH
[ ] No Irregularities Noted
APRIL
[ ] No Irregularities Noted
MAY
[ ] No Irregularities Noted
JUNE
[ ] No Irregularities Noted
JULY
[ ] No Irregularities Noted
AUGUST
[ ] No Irregularities Noted
SEPTEMBER
[ ] No Irregularities Noted
OCTOBER
[ ] No Irregularities Noted
NOVEMBER
[ ] No Irregularities Noted
DECEMBER
[ ] No Irregularities Noted
13.11
CONSULTANT PHARMACIST M.R.R. SIGNATURE LOG
YEAR:
MONTH
JANUARY
FEBRUARY
MARCH
APRIL
PATIENT NAME:
NOTES
_______________________________
REVIEW DATE
SIGNATURE
B.P.
WEIGHT
[ ] No Irregularities Noted
[ ] No Irregularities Noted
[ ] No Irregularities Noted
[ ] No Irregularities Noted
MAY
[ ] No Irregularities Noted
JUNE
[ ] No Irregularities Noted
JULY
[ ] No Irregularities Noted
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
DATE
[ ] No Irregularities Noted
[ ] No Irregularities Noted
[ ] No Irregularities Noted
[ ] No Irregularities Noted
[ ] No Irregularities Noted
LABS
13.12
13.13
13.14
NURSING HOME
CONSULTANT PHARMACIST PROGRESS REPORT
SAMPLE FACILITY
Date : 1/30/13
Name:
Doctor:
DOB:
Status:
Diet:
Diagnosis
Misc Info:
ADAMS, GUS
Station:
SOUTH
ATHER
Room:
201A
05/12/21
ADMIT 12/1/00
2000 CAL ADA – 2GM SODIUM
N/A
ASHD, CHF, COPD, DIABETES MELLITUS, PACEMAKER, ANEMIA, OBS WITH
DELUSIONAL PSYCHOSIS
Patient prefers to have meds crushed and in applesauce or pudding
Lab Due Dates: ELECTROLYTES 2/12/13
Lab Due Dates: CHEM-30 2/12/13
Jan 2013 Comments :
Dr Ather – Mr Adams is currently being treated with Lanoxin 0.125mg qd and Furosemide 40mg qd for CHF.
Worsening edema is documented in nursing notes over the past 6 weeks. Please review current therapy for possible
addition of an ACE Inhibitor
______________________________________________________
Consultant Pharmacist
Date : 1/30/13
Physician Follow-Up :____________________________________________________
Nursing Follow-Up :____________________________________________________
13.15
NURSING HOME
CONSULTANT PHARMACIST PROGRESS REPORT
SAMPLE FACILITY
Date : 2/20/13
Name:
Doctor:
DOB
Status
Diet
Diagnosis:
Misc Info:
ADAMS, GUS
Station:
SOUTH
ATHER
Room:
201A
05/12/21
ADMIT 12/1/00
2000 CAL ADA – 2GM SODIUM
N/A
ASHD, CHF, COPD, DIABETES MELLITUS, PACEMAKER, ANEMIA, OBS WITH
DELUSIONAL PSYCHOSIS
Patient prefers to have meds crushed in applesauce or pudding
Lab Due Dates: ELECTROLYTES 08/12/13
Lab Due Dates: CHEM-30 08/12/13
Feb 2013 Comments :
Progress Note – Dr Ather has agreed to add an ACE Inhibitor to current therapy in response to last months comment.
Prinivil was added on 2/2/13 and edema began improving within 10 days. B.P. and Pulse remain W.N.L.
_______________________________________________
Consultant Pharmacist
Date: 2/20/13
Physician Follow-Up :____________________________________________________
Nursing Follow-Up :____________________________________________________
(This is a sample of how a consultant might follow-up on a previous
recommendation. This note acknowledges that the MD responded to last months
comment and identifies the “outcome” of the change in therapy).
13.16
NURSING HOME
CONSULTANT PHARMACIST PROGRESS REPORT
SAMPLE FACILITY
Date : 12/7/2012
Name:
Doctor:
DOB:
Status:
Diet:
Diagnosis:
Misc Info:
ADAMS, GUS
Station: SOUTH
ATHER
Room:
201A
05/12/21
ADMIT 12/1/94
2000 CAL ADA – 2GM SODIUM
N/A
ASHD, CHF, COPD, DIABETES MELLITUS, PACEMAKER, ANEMIA,
DIABETIC NEUROPATHY
Patient prefers to have meds crushed and in applesauce or pudding
Lab Due Dates: ELECTROLYTES 02/12/03
Lab Due Dates: CHEM-30 02/12/03
Dec 7, 2012 Comments :
Phenytoin's effective level may be estimated by multiplying the patient's phenytoin level x 4.4 divided by
serum albumin. Since many geriatric patients have low serum albumin levels (3 - 3.5 g/l) the effective dose
of phenytoin in these patients is actually 25% to 50% higher than the reported levels. This is due to
decreased serum albumin binding and a higher "free drug fraction".
DR ATHER - your progress note on 12/5/2012 indicated that you are considering a psych consult due to
early symptoms of dementia. Please note that current dilantin level of 14.0 mcg/ml actually is equivalent to
a dilantin level of 20 mcg/ml due to a low albumin level (3.0). Cognitive changes may actually be related
to dilantin toxicity
_____________________________________________
Consultant Pharmacist
Date : 12/7/2012
Physician Follow-Up :____________________________________________________
13.17
COMMUNICATION SKILLS
YOUR STYLE WILL IMPACT PRESCRIBER RESPONSE
DO’s:
1. Always give the prescriber the benefit of the doubt since they may know more about
the patient than you do
2. Address the patient by name in your comment
3. Include relevant information since the prescriber may be reviewing your comments
outside of the facility (ex. Side effect occurred after a dose was increased)
4. Whenever possible leave the prescriber’s options open
5. Keep the comment concise and on point
6. Always write comments as a request (ex. “please consider”…. Or “Please review”)
7. If you anticipate a negative reaction to your comment consider talking to the physician
in person.
DON’Ts:
1. Don’t diagnosis in your consultant comment
2. Don’t write comments that will be perceived as increasing the prescriber’s liability
3. Don’t make jumps in logic that cannot be supported by the clinical information
available
4. Don’t give the prescriber 1 solution to the problem when multiple options exist.
CLINICAL SITUATION:
This 89 y/o female patient is currently taking captopril as part of her CHF therapy. Nursing notes indicate that a
cough developed 2 weeks ago. There are no cold symptoms noted or indications of worsening CHF. The consultant
needs to address the cough in his/her chart review
Consultants may communicate with different levels of effectiveness based on their communication skills
------------------------------------------------------------------------------------------------------Consultant 1
Dr Smith: Mrs. Jameson has had a chronic cough for the past 2 weeks. Please DC captopril order.
------------------------------------------------------------------------------------------------------Consultant 2
Mrs. Jameson is currently taking captopril 12.5mg T.I.D. for treatment of CHF. She has had a chronic cough for the
past 2 weeks which is being caused by the captopril. Please stop the drug as soon as possible.
-------------------------------------------------------------------------------------------------------Consultant 3
Mrs. Jameson is currently taking captopril 12.5mg T.I.D. for treatment of CHF. Patient developed a cough 2 weeks
ago. Please DC captopril and start losartan 25mg daily since cough is a side effect of captopril.
--------------------------------------------------------------------------------------------------------Consultant 4
Mrs. Jameson is currently taking captopril 12.5mg T.I.D. for treatment of CHF. Patient developed a cough 2 weeks
ago, shortly after increasing the dose of captopril from BID to TID. Nursing reports no indications of cold symptoms
or edema. Please review to determine if cough is related to the increase in ACE therapy. Consider a dosage reduction
in captopril or a change to ARB therapy if you feel this may be a side effect of current therapy.
13.18
USING CONSULTANT COMMENTS TO REDUCE YOUR LIABILITY
As mentioned in the previous section, Federal guidelines do not require the consultant to address
issues that have already been addressed by the attending physician. However, acknowledgement of
these issues in your consultant records provides evidence that you were aware of the issue, that it
was addressed by the physician (or facility) and may reduce your liability in the event of legal
action.
Examples of Consultant Comments:
A. Documenting Irregular Labs
1. Laboratory results on 12/1/12 identify multiple irregularities on CBC. These irregularities
are consistent with current diagnosis of chronic leukopenia. Dr Ather is aware of these
irregularities as indicated in 12/7/12 progress note.
2. Phenytoin level on 12/17/12 was low (8.0mcg/ml). Patient has had no seizure activity and
has had fluctuations in phenytoin levels over the past year. Dr Smith (neurologist) is aware
of current level and has elected to keep Phenytoin dose at 300mg/day and repeat levels in 4
weeks.
B. Documenting the Effectiveness of Pain Medications
1. Mrs James is taking PRN Vicodin for left hip pain approximately 5 to 6 times per week.
Nursing notes indicate that patient is requesting Vicodin prior to bedtime since her hip pain
interferes with sleep. Nursing notes and PRN sheet indicate good results within 1 hour of
dosing. All reports of pain throughout the day in nursing notes have been addressed by
nursing staff.
C. Rationalizing why you did not write an expected recommendation
1. Mrs. Howell is due for 6 month dosage reduction attempt for Risperdal 0.5mg QAM &
1mg at HS. Dr James (psychiatrist) saw patient last week and notes that behaviors have
escalated recently due to death of husband. He does not feel a dosage reduction attempt is
appropriate at this time. Dr Adams (attending) agrees with Dr James. I will hold comment
for dosage reduction attempt for 1-2 months and address at that time.
D. Recording an observation in progress notes
1. Mr Smith has been experiencing cough over the past several weeks. Patient is currently taking
captopril 12.5mg T.I.D. for CHF. Dr Casey indicates in 11/26/12 progress note that he does
not feel that cough is related to ACE therapy. He is treating cough with PRN Guiatuss DM.
13.19
E. Creating a plan of action
1. I will monitor PRN dose of Temazepam 7.5mg at bedtime. Usage has increased recently
and appears to be related to nursing changes on this unit. Will discuss with DON to
determine if patient’s insomnia has increased, if patient is requesting dose or whether
nursing staff is initiating the PRN order.
In each of these examples it could be argued that no consultant comment was required. Adding
these comments to your monthly documentation will increase the time for each chart review.
However, they will serve as an excellent chronology of your assessment and actions long after
nursing notes and charting records have been “thinned” from the chart. This may ultimately save
you time in subsequent months. In addition, these comments will help establish for the surveyor
that you identified these apparent irregularities and documented why no action was taken.
13.20
SAMPLE OF A MONTHLY SUMMARY REPORTS
SAMPLE FACILITY
Date : 12/31/12
Page 1
Report is for Month: December 2012
Dear Mrs. Smith:
Enclosed is a summary of this month's consultant pharmacist reports for your patients at Shady Rest.
Name:
Nursing Station:
Doctor:
ADAMS, GUS
SOUTH
ATHER
Room No.:
Maintenance RX’s:
PRNRX’s:
201A
RX’s
2
December Comments :
Phenytoin's effective level may be estimated by multiplying the patient's phenytoin level x 4.4 divided by serum
albumin. Since many geriatric patients have low serum albumin levels (3 - 3.5 g/l) the effective dose of phenytoin in
these patients is actually 25% to 50% higher than the reported levels. This is due to decreased serum albumin binding
and a higher "free drug fraction"
DR ATHER - Your progress note on 12/1/12 indicated that you are considering a psych consult due to early
symptoms of dementia. Please note that current dilantin level of 14.0 mcg/ml actually is equivalent to a dilantin level
of 20 mcg/ml due to a low albumin level (3.0). Cognitive changes may actually be related to dilantin toxicity.
--------------------------------------------------------------------------------------------------------------------------------Name:
Nursing Station:
Doctor:
CONRAD, FRANKLIN
NORTH
MEYER
Room No.:
Maintenance RX’s:
PRN RX’s:
125A
5
1
December Comments:
*No Irregularities Noted.
--------------------------------------------------------------------------------------------------------------------------------Name:
Nursing Station:
Doctor:
EMMETT, ESTHER
NORTH
MEYER
Room No.
Maintenance Rx;s:
PRN RX’s:
124A
3
2
December Comments:
*No Irregularities Noted.
-------------------------------------------------------------------------------------------------------------------------------Name:
Nursing Station:
Doctor:
EMMETT, MELVIN
NORTH
MEYER
Room No:
Maintenance RX’s:
PRN RX’s:
124B
6
3
December Comments :
DR MEYER - PLEASE REVIEW THE CURRENT ORDER FOR ZANTAC 150MG BID FOR POSSIBLE
DOSAGE REDUCTION. THIS ORDER HAS BEEN USED IN THERAPEUTIC DOSES SINCE 7/13/12.
13.21
NURSING HOME
SAMPLE OF A MONTHLY SUMMARY REPORTS
SAMPLE FACILITY
DATE: 12/31/12
Page 2
Name
Nursing Station:
Doctor:
GRIFFIN, ELVA
SOUTH
ATHER
Room No.:
Maintenance RX’s:
PRN RX’s
208B
7
1
December Comments :
*No Irregularities Noted *
--------------------------------------------------------------------------------------------------------------------------------Name:
Nursing Station:
Doctor:
KOEHLER, JANE
SOUTH
MEYER
Room No.:
Maintenance RX’s:
PRN RX’s
220A
5
0
December Comments:
DR MEYER - TO COMPLY WITH FEDERAL INDICATORS PLEASE REVIEW CURRENT ORDER FOR
LORAZEPAM 0.5MG TID (STARTED 9/1/12) FOR POSSIBLE DOSAGE REDUCTION.
-------------------------------------------------------------------------------------------------------------------------------Name:
Nursing Station:
Doctor:
OWENS, ROBERT
NORTH
MEYER
Room No.:
Maintenance RX’s:
PRN RX’s:
126A
4
3
December Comments :
No Irregularities Noted
--------------------------------------------------------------------------------------------------------------------------------Name:
Nursing Station:
Doctor:
ROBERTS, HARRIET
NORTH
ATHER
Room No.:
Maintenance RX’s:
PRN RX’s:
127A
5
1
December Comments :
* No Irregularities Noted *
--------------------------------------------------------------------------------------------------------------------------------Name:
Nursing Station:
Doctor:
WATERS, WALTER
SOUTH
MEYER
Room No.:
Maintenance RX’s:
PRN RX’s:
130A
3
2
December Comments :
DR MEYER - TO COMPLY WITH FEDERAL INDICATORS COULD WE OBTAIN A CARDIAC DIAGNOSIS
TO SUPPORT THE USE OF NITROGLYCERIN SR CAPSULES.
13.22
NURSING HOME
SAMPLE OF A MONTHLY SUMMARY REPORTS
SAMPLE FACILITY
Date: 12/31/12
Page 3
Name:
Nursing Station:
Doctor:
WINTERS, MARTHA
SOUTH
MEYER
Room No.:
Maintenance RX’s:
PRN RX’s:
204A
3
2
December Comments :
PHARMACY NOTE - PATIENT WAS HOSPITALIZED ON 12/1/2012 WITH S.O.B. CONFUSION AND
FEVER. PATIENT RETURNED WITH DIAGNOSIS OF PNEUMONIA AND IS CURRENTLY RECEIVING
ROCEPHIN
The Totals are for all patients in facility :
Average Number of Maintenance per Patient
Average Number of PRN per Patient
Average Number of Drugs per Patient
4.6
1.7
6.3
Sincerely,
______________________________________
Consultant Pharmacist
13.23
ICF –DD
QUARTERLY PROGRESS REPORT (SAMPLE)
Date : 12/31/2012
Name:
Doctor:
DOB:
Status:
Diet:
JOHNSON, THOMAS
ATHER
05/12/69
ADMIT 12/1/01
REGULAR
Diagnosis:
MENTAL RETARDATION, OBS W PSYCHOSIS, ESSTENTIAL
TREMOR, RHINITIS
Patient prefers to have meds crushed and in applesauce or pudding
Misc Info:
Station:
Room:
SOUTH
201B
Lab Due Dates: ELECTROLYTES 02/12/12
Lab Due Dates: CHEM-30 02/12/12
Dec 31, 2012 Comments :
General health remains stable at this time although tremor still noted. These fine tremors are unchanged in frequency
or intensity and do not affect ADL’s.
Dr Thomas provided annual eye exam on 11/4/12 – normal eye exam – no new orders.
Dr. Adams provided psych review on 11/1/12. He notes Thomas is doing well on current orders for Thioridazine
100mg TID, Clonazepam 0.5mg TID and Benztropine 1mg TID – no new orders as of this review. Repeat psych
review on 12/6 indicates some “weird” behaviors with an increase in “spaciness” and wandering. Dr Adams
requested an EKG due to black box warning on Thioridazine.
Elimite treatment completed on 11/30 and 12/6 for scabies outbreak. Infection resolved as of this review with no
adverse effects from Elimite therapy.
U/A and C&S was ordered on 12/10 for cloudy urine. Based on results of C&S Levaquin 500mg qd x 7days was
ordered for UTI. Infection resolved by 12/17.
EKG was completed on 12/18. Results were abnormal with suspect evidence of inferior infact. Referred to Dr
Hogan (cardiologist) for consult. Dr Hogan has ordered echocardiogram but will not see patient until January 6th.
Psych review meeting on 12/30 – discussed dc’ing Thioridazine due to cardiac issues however the team agreed that
Thioridazine will be continued until after the cardiology workup is completed. Continue to monitor frequency of
tremor and for EPS and TD secondary to Thioridazine therapy. DISCUS review should be completed before January
15th.
Current therapy should not affect dietary requirements. There are no significant food-drug interactions noted.
_____________________________________________
Edward Meyer - Consultant Pharmacist
Date : 12/31/12
13.24
NURSING HOME
SAMPLE REPORT
QUARTERLY PHARMACY REVIEW OF SAMPLE FACILITY
JULY 2012 THROUGH SEPTEMBER 2012
A Total of 55 Hours Of Consultant Time Was Spent In The Facility During This Quarter.
A Total of 68 Recommendations Have Been Left This Quarter. These Recommendations Can Be Broken Down Into
The Following Categories:
0 - Involved Missing Blood Pressures When Required
7 - Involved Missing Pulses When Lanoxin Was In Use
0 - Involved Missing Or Incomplete Diagnosis
27 -Involved Charting Omissions
2 - Involved Incomplete Documentation On Administered Prn's.
2 - Involved Suggested Changes In Current Therapy.
0 - Involved Suggested Lab Work
7 - Involved Missing Information On Prn Order
15 -Involved An Antipsychotic Order
8 - Involved An Anxiolytic Order
I. PATIENT MEDICATIONS
The meds were found to be well organized with current labels. There were minimal duplications noted. All liquid
containers and liquid cabinets were found clean. No outdated patient meds were found this quarter.
II. TREATMENT CARTS
Treatment cabinets and carts were found very neat throughout the quarter. There were no outdated products found.
All treatments contained current labels. No discontinued products were noted.
III. REFRIGERATED MEDS
All three refrigerators were found to be in the safe zone throughout the quarter. There was no frost build-up and no
food products were found this quarter. Puncture dates and expiration dates on insulin and miacalcin remained clean
this quarter.
IV. MEDICATION RECORD SHEETS
Medication sheets were in general neat and orderly. Charting omissions were down this quarter. The reporting of
episodes and side effects on antipsychotic and anxiolytic flow sheets remains good during the past quarter.
V. CONTROLLED SUBSTANCES
Controlled substances were destroyed during August.
VI. REFERENCE MATERIALS
All needed reference materials are present at each nursing station. The procedure manual was completely reviewed
and updated during september.
VII. EMERGENCY BOXES
All 3 EDK's were found to be in good order throughout the quarter.
13.25
VIII. PRESCRIPTION USAGE
1ST FLOOR
2ND FLOOR
3RD FLOOR
JULY
8.6
6.7
9.4
AUGUST
8.6
6.3
9.3
SEPTEMBER
7.9
6.5
9.0
FACILITY AVERAGE
8.0
8.0
7.8
IX. PSYCHOACTIVE USE IN THE FACILITY
PATIENTS
% OF POP
AS OF 12/2012
PATIENTS
PATIENTS
PATIENTS
PATIENTS
ON ANTIPSYCHOTICS
ON ANXIOLYTICS
ON ANTIDEPRESSANTS
W O.B.S. OR DEMENTIA
22
28
30
79
18%
23%
25%
66%
AS OF 9/12
PATIENTS
PATIENTS
PATIENTS
PATIENTS
ON ANTIPSYCHOTICS
ON ANXIOLYTICS
ON ANTIDEPRESSANTS
W O.B.S. OR DEMENTIA
27
42
41
68
23%
35%
34%
57%
AS OF 6/12
PATIENTS
PATIENTS
PATIENTS
PATIENTS
ON ANTIPSYCHOTICS
ON ANXIOLYTICS
ON ANTIDEPRESSANTS
W O.B.S. OR DEMENTIA
21
40
34
70
17.5%
33%
28%
58%
AS OF 3/12
PATIENTS
PATIENTS
PATIENTS
PATIENTS
ON ANTIPSYCHOTICS
ON ANXIOLYTICS
ON ANTIDEPRESSANTS
W O.B.S. OR DEMENTIA
27
35
36
71
22.5%
29%
30%
59%
SINCERELY,
CONSULTANT PHARMACIST
(Note: There is no standard format for the quarterly
report. This represents just one example of how
quarterly report can be structured.)
SAMPLES OF CHARTING MATERIALS
13.26
13.27